A 31-year-old male presented to the emergency department (ED) at 9:00 a.m. for evaluation of bilateral low abdominal pain, vomiting, and diarrhea that began earlier that morning. He was seen by a triage nurse who documented a set of vital signs (T 96.0, P 81, BP 115/60); a history significant for a right anterior cruciate ligament reconstruction; and a medication list that included Plavix and Oxycontin. The triage note also included a statement by the patient that he had been seen, at another ED, for similar symptoms two weeks prior and diagnosed with narcotics withdrawal.
A nursing flow sheet begun at 9:30 a.m. noted that the patient appeared diaphoretic and pale. He was doubled over with “multiple ecchymotic areas over his entire body,” and states “he is withdrawing from Oxycontin.” The on-duty physician (a moonlighting gastroenterologist) examined the patient and an intravenous line was established; he was treated with 1000 ml of normal saline. A second set of vital signs was recorded at 10:00 a.m. (HR 67, RR 20, BP 96/45).
The physician’s evaluation noted “moderate distress,” and on abdominal exam “faint bowel sounds, soft, nontender except for mild tenderness bilaterally in the lower quadrants… no rebound or guarding.”
Laboratory evaluation revealed a white blood count of 12.3; hematocrit normal; platelet count 346,000; and normal basic chemistry and liver function tests. Radiographs (KUB and upright) were interpreted to reveal a non-specific bowel gas pattern. The physician made a diagnosis of narcotic withdrawal, referring to the patient’s history of opioid dependence for chronic pain following his knee operation, as well as to a recent visit for abdominal pain to another hospital, where he was diagnosed with narcotic withdrawal. After treatment with Compazine and clonidine, improvement in the patient’s symptoms was documented.
The patient declined a referral to a detox center. He was discharged at 3:00 p.m. with a prescription for a clonidine patch and instructions to follow up for detox. He filled his prescription and went home. Later that evening, his wife found him on the bathroom floor, unresponsive. EMS providers, who were dispatched at 9:00 p.m., found him to be in an asystolic cardiac arrest; CPR was performed. He was transported back to the hospital, where CPR was continued, but died at 10:30 p.m.
Autopsy identified a sigmoid perforation with associated peritonitis and septicemia as the cause of death. A later finding of Ehrlers Danlos syndrome in the patient’s daughter raised the possibility of a predisposing condition.